Dr Hania Kassem @kassem_hania is a faculty member at the section of Nephrology at Baylor College of Medicine. She has a special interest in CKD and home dialysis. She is also very passionate about teaching and has won multiple teaching awards.
When it comes to choosing a dialysis modality, patients’ goals of care and quality of life are essential considerations. While we discuss with our patients outcomes such as hospitalization, cardiovascular disease, and mortality, we also realize that patients choosing a dialysis modality are facing a life changing event that they potentially have to live with for a prolonged period of time. With recent Kidney Disease Improving Global Outcomes (KDIGO) controversies conferences recommending an individualized approach to dialysis initiation and managing dialysis symptom burden, having more options to offer becomes increasingly important. Integrated home dialysis consists of combining two home dialysis modalities, peritoneal dialysis (PD) initially followed by a planned transition to home hemodialysis (HHD). This model may provide an appealing alternative to any of the traditional individual dialysis modalities for multiple reasons.
Advantages and disadvantages of integrated home dialysis. © Kassem
Dialysis as a technique may initially be overwhelming for a patient who is not familiar with it. Patients may be more hesitant to consider a home modality such as HHD that involves them performing self-cannulation, handling blood, and administering fluid for resuscitation than to consider PD. In a review by Hussein et al about patients’ involvement in dialysis care, the authors report that patient activation (a measure of a patients’ ability and desire to manage their own health) is lower in patients undergoing in-center hemodialysis compared to PD patients. Being on PD may empower the patients to take a more active role in their healthcare and prepare them to undertake home hemodialysis at a later stage. Other advantages to an integrated home dialysis model include less time on either modality, resulting in a lower likelihood of time-dependent complications such as the metabolic complications and the encapsulating peritoneal sclerosis that are seen with long term PD, and the need for multiple vascular accesses with long term hemodialysis.
In a recent analysis of the Canadian Organ Replacement Register by Desbiens et al published in AJKD, the authors compared patients who started with PD within 90 days of initiation of dialysis and transitioned successfully to HHD within 90 days of stopping PD to matched patients who started HHD within 90 days of dialysis initiation. The authors performed an incident-match analysis where follow-up started at the patients’ first day of HHD in both groups as well as a vintage-match analysis where follow-up started at the initiation of HHD in the integrated home dialysis patients and after an equivalent time on dialysis in the matched HHD group. The latter analysis showed that compared to the HHD group, the PD to HHD patients had a lower risk of the composite outcome of all-cause mortality and modality transfer and a similar risk of hospitalization. The authors however acknowledge multiple limitations of the analysis, especially since only 3.6% of patients in the registry successfully transitioned from PD to HHD.
Other studies (including Elbokl et al, Kansal et al, and a pair of studies from Nadeau-Fredette et al) also showed favorable outcomes associated with integrated home dialysis care.
© Kassem
In conclusion, an integrated home dialysis care model starting with PD with a planned transition to HHD ensures keeping the patients at home, provides multiple advantages, and has similar and in some cases superior outcomes compared to the traditional individual dialysis modalities.
– Post prepared by Hania Kassem @kassem_hania
To view Desbiens et al (Open Access), please visit AJKD.org.
Title: Outcomes of Integrated Home Dialysis Care: Results From the Canadian Organ Replacement Register
Authors: Louis-Charles Desbiens, Karthik K. Tennankore, Rémi Goupil, Jeffrey Perl, Emilie Trinh, Christopher T. Chan, Annie-Claire Nadeau-Fredette
DOI: 10.1053/j.ajkd.2023.05.011